Physicians and patients alike tend to avoid frank discussions about “code status” — whether a patient would want CPR or mechanical ventilation in the event of a cardiac or respiratory arrest. When doctors address code status at all, they tend to phrase the questions in such a way to cut off any thoughtful discussion: “If [… read more]

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “… And you may ask yourself … well, how did I get here? … And you may tell yourself … my God! What have I done?” -David Byrne A 92 year old woman is transferred to the coronary care unit for treatment of pulmonary edema. She [… read more]

The common cold is aptly named, with an estimated 500 million infections annually in the United States. Adults in the U.S. average two to three colds per year, and preschool children five to seven. Colds create a huge economic burden from missed work days, health care visits and medications, an estimated $17 billion directly and [… read more]

Oral corticosteroids are frequently prescribed for persistent cough after the common cold in patients without respiratory disease. Like much of what physicians offer or advise, steroids for ordinary cough are traditionally provided not based on evidence, but on the premise that “it might help.” A new study in JAMA substantially undermines that premise. Authors randomized [… read more]

In pulmonary embolism (PE), right ventricular (RV) strain on transthoracic echocardiography increases the likelihood of shock and mortality. One study showed among patients with PE and normal blood pressure, 10% of those with RV strain on echocardiogram developed shock, and 5% died in hospital. Those without RV strain maintained their blood pressure and survived (but important [… read more]

This would be a very informative case report (and it’s true and unexaggerated), but I anticipate staunch editorial resistance (even sans puns), so I’ll describe it here and have some fun with it. Background: The author has anecdotally observed for many years that so-called “septic shock” follows rather than precedes intubation and sedation. This raises [… read more]

Jon-Emile S. Kenny MD [@heart_lung] In the last few weeks I have been contacted by curious clinical physiologists craving my conceptions of ‘venous excess’ [1]. These words will address this model, concisely and – I pray – clearly. The Myth of Venous Return The roots of venous excess took hold within the fertile soil of [… read more]

The US Food and Drug Administration (FDA) approved an implanted phrenic nerve-stimulator device as a new treatment for moderate-to-severe central sleep apnea (CSA). The remedē System (Respicardia) consists of a pacemaker-like battery pack that’s surgically implanted in the upper chest beneath the skin. Wires electrically stimulate the phrenic nerve as it travels from the neck [… read more]

When the Centers for Medicare and Medicaid Services (CMS) released its 2015 performance measure for the treatment of sepsis — called SEP-1 or the Severe Sepsis/Septic Shock Early Management Bundle, physicians responded with general befuddlement: the measure demanded they follow such unusual practices as giving 3-liter boluses of saline to anuric, hypertensive, hypoxemic patients with [… read more]

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are one of the top causes of hospital admission — and readmission: up to 30% of patients “bounce back” to the hospital within 90 days after a COPD exacerbation. Patients with severe COPD exacerbations with acute hypercapneic respiratory failure often receive noninvasive ventilation (NIV), commonly known as [… read more]

The antifungal micafungin is often given empirically to patients in ICUs with sepsis who are also at high risk for invasive fungal infections. IDSA guidelines endorse the use of empiric antifungals for patients with unresolving ICU-acquired sepsis, but any benefits of this are unknown. A randomized trial published in JAMA sheds light on the practice. French [… read more]

Treating Pain in Mechanically Ventilated Patients Adult patients in the intensive care unit (ICU) frequently experience pain, resulting from acute and chronic illness as well the positioning and interventions standard to ICU care.1,2 Besides being ethical and humane, adequately treating pain prevents agitation and delirium in mechanically ventilated patients. There are also many physiologic responses to [… read more]

The FDA is warning physicians not to provide other enterally-absorbed drugs within 3 hours before or after giving sodium polystyrene sulfonate (Kayexalate, Concordia Pharmaceuticals) for hyperkalemia. In testing performed 59 years after its launch, it was discovered that Kayexalate can bind to many prescription drugs, potentially rendering them ineffective. For patients with gastroparesis or ileus, FDA [… read more]

U.S. medical centers vary widely in the average shelf life of the blood in their blood banks. Trauma and high-volume surgical centers receive the oldest blood from the Red Cross, on the premise that they’ll be likely to transfuse it. All blood banks tend to dispense the oldest units first. This reduces waste of donated [… read more]

In the U.S., the federal government strongly encourages physicians to give most patients with sepsis aggressive crystalloid fluid boluses (~2-3 liters), without regard to a patient’s individual condition. In a randomized trial in JAMA, a similar standardized approach to aggressive fluid resuscitation in Africa appeared to cause the deaths of a significant proportion of patients [… read more]

Jon-Emile S. Kenny MD [@heart_lung] “To believe in medicine would be the height of folly, if not to believe in it were not a greater folly still.” -Proust A 32 year old man with no past medical history save for a BMI of 51 is admitted with severe acute pancreatitis following a large intake of [… read more]